Archive for July 9, 2010

Recommended Adult Immunization Schedule: United States, 2010*

Ann Intern Med 5 January 2010  V.152  N.1  p.36-39

Clinical Guidelines

Advisory Committee on Immunization Practices†

From the Centers for Disease Control and Prevention, Atlanta, Georgia.

The Advisory Committee on Immunization Practices (ACIP) annually reviews the Recommended Adult Immunization Schedule (Figure) to ensure that the schedule reflects current recommendations for the licensed vaccines. In October 2009, ACIP approved the Adult Immunization Schedule for 2010, which includes several changes. A bivalent human papillomavirus vaccine (HPV2) was licensed for use in females in October 2009. The ACIP recommends vaccination of females with either HPV2 or the quadrivalent human papillomavirus vaccine (HPV4). HPV4 was licensed for use in males, and the ACIP used a permissive recommendation for use of this vaccine in males. Introductory sentences were added to the footnotes for measles, mumps, rubella, influenza, pneumococcal, hepatitis A, hepatitis B, and meningococcal vaccines. Clarifications were made to the footnotes for measles, mumps, rubella, influenza, hepatitis A, meningococcal, and Haemophilus influenzae type B (Hib) vaccines, and schedule information was added to the hepatitis B vaccine footnote….



July 9, 2010 at 2:05 am Leave a comment

Comparison of 2 Interventions for Liquid Aspiration on Pneumonia Incidence

Ann Intern Med  1 April 2008  V.148  N.7  p.509-518

A Randomized Trial

JoAnne Robbins, PhD; Gary Gensler, MS; Jacqueline Hind, MS; Jeri A. Logemann, PhD; Anne S. Lindblad, PhD; Diane Brandt, BS; Herbert Baum, PhD; David Lilienfeld, MD, PhD; Steven Kosek, MS; Donna Lundy, PhD; Karen Dikeman, MA; Marta Kazandjian, MA; Gary D. Gramigna, MS; Susan McGarvey-Toler, MS; and Patricia J. Miller Gardner, JD

From William S. Middleton Memorial Veterans Hospital, Geriatric Research Education and Clinical Center, and University of Wisconsin, Madison, Wisconsin; EMMES Corporation and American Speech-Language-Hearing Association, Rockville, Maryland; Northwestern University, Evanston, Illinois; ORC Macro, Calverton, Maryland; Stanford University School of Medicine, Palo Alto, California; Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota; University of Miami Hospital and Clinics, Miami, Florida; New York Hospital Medical Center–Queens, Flushing, New York; Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts; and Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana.


Aspiration pneumonia is common among frail elderly persons with dysphagia. Although interventions to prevent aspiration are routinely used in these patients, little is known about the effectiveness of those interventions.


To compare the effectiveness of chin-down posture and 2 consistencies (nectar or honey) of thickened liquids on the 3-month cumulative incidence of pneumonia in patients with dementia or Parkinson disease.


Randomized, controlled, parallel-design trial in which patients were enrolled for 3-month periods from 9 June 1998 to 19 September 2005.


47 hospitals and 79 subacute care facilities.


515 patients age 50 years or older with dementia or Parkinson disease who aspirated thin liquids (demonstrated videofluoroscopically). Of these, 504 were followed until death or for 3 months.


Participants were randomly assigned to drink all liquids in a chin-down posture (n = 259) or to drink nectar-thick (n = 133) or honey-thick (n = 123) liquids in a head-neutral position.


The primary outcome was pneumonia diagnosed by chest radiography or by the presence of 3 respiratory indicators.


52 participants had pneumonia, yielding an overall estimated 3-month cumulative incidence of 11%. The 3-month cumulative incidence of pneumonia was 0.098 and 0.116 in the chin-down posture and thickened-liquid groups, respectively (hazard ratio, 0.84 [95% CI, 0.49 to 1.45]; P = 0.53). The 3-month cumulative incidence of pneumonia was 0.084 in the nectar-thick liquid group compared with 0.150 in the honey-thick liquid group (hazard ratio, 0.50 [CI, 0.23 to 1.09]; P = 0.083). More patients assigned to thickened liquids than those assigned to the chin-down posture intervention had dehydration (6% vs. 2%), urinary tract infection (6% vs. 3%), and fever (4% vs. 2%).


A no-treatment control group was not included. Follow-up was limited to 3 months. Care providers were not blinded, and differences in cumulative pneumonia incidence between interventions had wide CIs.


No definitive conclusions about the superiority of any of the tested interventions can be made. The 3-month cumulative incidence of pneumonia was much lower than expected in this frail elderly population. Future investigation of chin-down posture combined with nectar-thick liquid may be warranted to determine whether this combination better prevents pneumonia than either intervention independently.




July 9, 2010 at 2:03 am Leave a comment

Antiretroviral Regimens in Pregnancy and Breast-Feeding in Botswana

New England Journal of Medicine, June 17, 2010  V.362  N.24  p.2282-2294

R.L. Shapiro, M.D., M.P.H., M.D. Hughes, Ph.D., A. Ogwu, M.B., B.S., D. Kitch, M.S., S. Lockman, M.D., C. Moffat, M.B., Ch.B., M.P.H., J. Makhema, M.B., Ch.B., M.R.C.P., S. Moyo, M.P.H., I. Thior, M.D., K. McIntosh, M.D., E. van Widenfelt, B.S., J. Leidner, M.S., K. Powis, M.D., M.P.H., A. Asmelash, M.D., M.P.H., E. Tumbare, M.B., Ch.B., S. Zwerski, M.S.N., U. Sharma, Ph.D., M.P.H., E. Handelsman, M.D., K. Mburu, B.Pharm., O. Jayeoba, M.B., Ch.B., E. Moko, M.B., Ch.B., S. Souda, M.D., E. Lubega, M.D., M. Akhtar, M.B., Ch.B., C. Wester, M.D., M.P.H., R. Tuomola, M.D., W. Snowden, Ph.D., M. Martinez-Tristani, M.D., L. Mazhani, M.D., and M. Essex, D.V.M., Ph.D.

From the Division of Infectious Diseases, Beth Israel Deaconess Medical Center (R.L.S.); the Departments of Immunology and Infectious Diseases (R.L.S., S.L., I.T., K. McIntosh, J.L., M.E.) and Biostatistics (M.D.H., D.K.), Harvard School of Public Health; the Infectious Disease Unit (S.L.) and the Department of Obstetrics, Gynecology, and Reproductive Biology (R.T.), Brigham and Women’s Hospital; the Division of Infectious Diseases, Children’s Hospital (K. McIntosh); and the Departments of Medicine and Pediatrics, Massachusetts General Hospital (K.P.); — all in Boston; the Botswana Harvard AIDS Institute (A.O., C.M., J.M., S.M., I.T., E.W., A.A., E.T., K. Mburu, O.J., E.M., S.S., E.L., M.A., C.W.) and the Botswana Ministry of Health (L.M.) — both in Gaborone, Botswana; the National Institutes of Health, National Institute of Allergy and Infectious Diseases, Bethesda, MD (S.Z., U.S., E.H.); GlaxoSmithKline, Greenford, United Kingdom (W.S.); and Abbott Virology, Abbott Park, IL (M.M.-T.).


The most effective highly active antiretroviral therapy (HAART) to prevent mother-to-child transmission of human immunodeficiency virus type 1 (HIV-1) in pregnancy and its efficacy during breast-feeding are unknown.


We randomly assigned 560 HIV-1–infected pregnant women (CD4+ count, 200 cells per cubic millimeter) to receive coformulated abacavir, zidovudine, and lamivudine (the nucleoside reverse-transcriptase inhibitor [NRTI] group) or lopinavir–ritonavir plus zidovudine–lamivudine (the protease-inhibitor group) from 26 to 34 weeks’ gestation through planned weaning by 6 months post partum. A total of 170 women with CD4+ counts of less than 200 cells per cubic millimeter received nevirapine plus zidovudine–lamivudine (the observational group). Infants received single-dose nevirapine and 4 weeks of zidovudine.


The rate of virologic suppression to less than 400 copies per milliliter was high and did not differ significantly among the three groups at delivery (96% in the NRTI group, 93% in the protease-inhibitor group, and 94% in the observational group) or throughout the breast-feeding period (92% in the NRTI group, 93% in the protease-inhibitor group, and 95% in the observational group). By 6 months of age, 8 of 709 live-born infants (1.1%) were infected (95% confidence interval [CI], 0.5 to 2.2): 6 were infected in utero (4 in the NRTI group, 1 in the protease-inhibitor group, and 1 in the observational group), and 2 were infected during the breast-feeding period (in the NRTI group). Treatment-limiting adverse events occurred in 2% of women in the NRTI group, 2% of women in the protease-inhibitor group, and 11% of women in the observational group.


All regimens of HAART from pregnancy through 6 months post partum resulted in high rates of virologic suppression, with an overall rate of mother-to-child transmission of 1.1%.



July 9, 2010 at 2:01 am Leave a comment

Maternal or Infant Antiretroviral Drugs to Reduce HIV-1 Transmission

New England Journal of Medicine, June 17, 2010  V.362  N.24  p.2271-2281

Charles S. Chasela, Ph.D., Michael G. Hudgens, Ph.D., Denise J. Jamieson, M.D., M.P.H., Dumbani Kayira, M.B., B.S., Mina C. Hosseinipour, M.D., M.P.H., Athena P. Kourtis, M.D., Ph.D., Francis Martinson, M.B., Ch.B., Ph.D., Gerald Tegha, B.Sc., Rodney J. Knight, Ph.D., Yusuf I. Ahmed, B.M., Deborah D. Kamwendo, M.Sc., Irving F. Hoffman, P.A., M.P.H., Sascha R. Ellington, M.S.P.H., Zebrone Kacheche, B.Sc., Alice Soko, R.N., Jeffrey B. Wiener, Ph.D., Susan A. Fiscus, Ph.D., Peter Kazembe, M.B., Ch.B., Innocent A. Mofolo, M.Sc., Maggie Chigwenembe, R.N., Dorothy S. Sichali, B.Sc., Charles M. van der Horst, M.D., for the BAN Study Group

From the University of North Carolina Project, Lilongwe, Malawi (C.S.C., D.K., M.C.H., F.M., G.T., D.D.K., Z.K., A.S., I.A.M., M.C., D.S.S.); the University of North Carolina (M.G.H., M.C.H., D.D.K., I.F.H., S.A.F., P.K., I.A.M., C.M.H.) and Principia (R.J.K.) — both in Chapel Hill; and the Centers for Disease Control and Prevention, Atlanta (D.J.J., A.P.K., Y.I.A., S.R.E., J.B.W.).


We evaluated the efficacy of a maternal triple-drug antiretroviral regimen or infant nevirapine prophylaxis for 28 weeks during breast-feeding to reduce postnatal transmission of human immunodeficiency virus type 1 (HIV-1) in Malawi.


We randomly assigned 2369 HIV-1–positive, breast-feeding mothers with a CD4+ lymphocyte count of at least 250 cells per cubic millimeter and their infants to receive a maternal antiretroviral regimen, infant nevirapine, or no extended postnatal antiretroviral regimen (control group). All mothers and infants received perinatal prophylaxis with single-dose nevirapine and 1 week of zidovudine plus lamivudine. We used the Kaplan–Meier method to estimate the cumulative risk of HIV-1 transmission or death by 28 weeks among infants who were HIV-1–negative 2 weeks after birth. Rates were compared with the use of the log-rank test.


Among mother–infant pairs, 5.0% of infants were HIV-1–positive at 2 weeks of life. The estimated risk of HIV-1 transmission between 2 and 28 weeks was higher in the control group (5.7%) than in either the maternal-regimen group (2.9%, P=0.009) or the infant-regimen group (1.7%, P<0.001). The estimated risk of infant HIV-1 infection or death between 2 and 28 weeks was 7.0% in the control group, 4.1% in the maternal-regimen group (P=0.02), and 2.6% in the infant-regimen group (P<0.001). The proportion of women with neutropenia was higher among those receiving the antiretroviral regimen (6.2%) than among those in either the nevirapine group (2.6%) or the control group (2.3%). Among infants receiving nevirapine, 1.9% had a hypersensitivity reaction.


The use of either a maternal antiretroviral regimen or infant nevirapine for 28 weeks was effective in reducing HIV-1 transmission during breast-feeding





Protecting the Next Generation — Eliminating Perinatal HIV-1 Infection

Lynne M. Mofenson, M.D.

From the Pediatric, Adolescent and Maternal AIDS Branch, Center for Research for Mothers and Children, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, MD.

More than 90% of the 430,000 human immunodeficiency virus type 1 (HIV-1) infections in children each year occur in sub-Saharan Africa, where HIV-1 acquisition through breast milk accounts for more than 40% of infections. However, in Africa, breast-feeding is a cornerstone of child survival. Two randomized trials reported in this issue of the Journal1,2 show that antiretroviral regimens in breast-feeding infants or lactating mothers significantly decrease postnatal acquisition of HIV-1. It should be possible to eliminate new perinatal HIV-1 infections globally with the use of antiretroviral therapy when needed for maternal health and, when treatment is not otherwise required for the mother’s health, by adding postpartum prophylaxis to antepartum and intrapartum prophylaxis…..

Full Text    


July 9, 2010 at 2:00 am Leave a comment

Syphilis: review with emphasis on clinical, epidemiologic, and some biologic features.

Clin Microbiol Rev. 1999 Apr;12(2):187-209.

Singh AE, Romanowski B.

Alberta Health STD Services, University of Alberta, Edmonton, Alberta, Canada.


Syphilis is a chronic disease with a waxing and waning course, the manifestations of which have been described for centuries. It occurs worldwide, and the incidence varies significantly with geographic location. Transmission is mainly by sexual contact. The causative organism, Treponema pallidum, was first described in 1905, but because of the inability to culture the organism and the limitations of direct microscopy, serologic testing is the mainstay of laboratory diagnosis. The disease has been arbitrarily divided into several stages. The primary stage is defined by a chancre at the site of inoculation. The secondary stage is characterized by a polymorphic rash, lymphadenopathy, and other systemic manifestations. A variable asymptomatic latent period follows, which for epidemiologic purposes is divided into early (<1 year) and late (>1 year) stages. The early stages (primary, secondary, and early latent) are potentially infectious. The tertiary stage is the most destructive and is marked by cardiovascular and neurologic sequelae and gummatous involvement of any organ system. Congenital infection may result in protean early or late manifestations. Unlike many other bacteria causing infectious diseases, the organism remains sensitive to penicillin, and this remains the mainstay of therapy.



July 9, 2010 at 1:57 am Leave a comment


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